![]() OTHER HEALTH INSURANCE - I certify that the insurance information that I have provided is accurate, complete and current and that no other coverage or insurance exists. I authorize Connect Hearing or its subcontractors to release to my Health Insurance Plan such information needed to determine these benefits or the benefits payable for related services. If my Health Insurance Plan will not remit payment to Connect Hearing, I agree to forward to Connect Hearing all health insurance payments, which I receive for the services rendered by Connect Hearing and its personnel. I authorize Connect Hearing to file an appeal on my behalf for any denial of payment and/or any adverse benefit determination related to services and care provided. ASSIGNMENT OF BENEFITS - By signing below, I request that payment of authorized benefits be made on my behalf to Connect Hearing for any services furnished the client listed above by Connect Hearing personnel, and I assign my right to receive these payments to Connect Hearing. Insurance Agreement * This field is required. I have notified the clinician now present of any medications or conditions that could impact this procedure. In the event of uncommon abrasion or trauma, I will be referred back to my PCP or an ENT for treatment. Otoscope inspection of my ear will be performed before and after the procedure. ![]() Small abrasions and slight bleeding are not uncommon. For deep canal impressions, the procedure may be somewhat uncomfortable, but may be necessary for the effectiveness of the recommended hearing instrument. ![]() I understand that the cerumen removal process and/or the impression taking of my ear(s) is a semi‐ invasive procedure and that there is always the possibility of trauma to the skin in my ear canal or the tympanic membrane. On behalf of myself or my dependents, if I choose to order earmolds, ear protection, or hearing instruments or have them repaired, I hereby authorize the relevant procedures to be performed, possibly including the insertion of silicone or similar material into the ear canal to obtain ear impressions. Consent for Treatment * This field is required.
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